to detect problems that might affect the woman's pregnancy and require additional care - routinely screen for anemia, hypertension, HIV, syphilis and diabetes mellitus. Recognize other problems that may complicate pregnancy: malnutrition and tuberculosis, vaginal bleeding, vaginal discharge, fetal distress and abnormal fetal position after 36 weeks Danger and emergency signs: Fever, vaginal bleeding, headache and blurring of vision, severe abdominal pain, convulsion, severe difficulty of breathing Birth and emergency plan
The World Health Organization (WHO) recommends giving ferrous sulfate 320 milligrams (60 mg of elemental iron) twice a day to all pregnant women. If the woman’s hemoglobin is 8 gm or less at any visit, increase her iron supplementation to three times a day for the entire pregnancy. If ferrous sulfate is not available, give an equal amount of elemental iron in another iron preparation.
Distinguish chronic hypertension, pre-eclampsia and severe pre-eclampsia. These patients should be referred to the doctor
Nutrition – what food to eat and what foods to avoid during pregnancy. Self-care during pregnancy – the importance of hygiene Discuss breastfeeding and benefits during the prenatal consultation. Explain the danger signs and the signs of labor.
Diagnosis of pregnancy &antenatal care for undergraduate
Diagnosis of pregnancy DR: MANAL BEHERYZagazig University , Egypt
Principles of diagnosisIn the majority of women, the diagnosis of pregnancy is usually straightforward based on a history of amenorrhea and a positive pregnancy test.women with irregular periods or irregular vaginal bleeding , the diagnosis of pregnancy is more complex. Other symptoms of pregnancy may alert the clinician to the possibility of pregnancy.
Symptoms of pregnancy:Amenorrhoea: HOWEVERPregnancy may occur during period of lactation amenorrhea.Slight bleeding early in pregnancy (threatened abortion) may be considered by the patient as menses .Hartmans symptoms: slight bleeding occurs at time of menstruation
Symptoms of pregnancy:Morning sickness: nausea, rarely vomiting confined to morningIncreased frequency of micturition.Enlargement of the breast and sensation of heaviness.Easy fatiguability and tendency to sleep.Emotional changes e.g. change of the appetite:
In the second and third trimesters1-Abdominal enlargement2-Quickening -1st perception (sensation) of fetal movements by the lady-PG (18-20 weeks), MP (16-18 weeks)
Auscultation: Auscultation of FHS as early as 10-12 weeks by sonicadeAuscultation of FHS as early as 20-24 weeks by Pinard stethoscopeAuscultation of umbilical souffle as early as 20-24 weeks.Auscultation of uterine souffl
Pregnancy tests: Principle:Detection ofHCG in the urine orserum .
1- Urinary pregnancy test:Classically it becomes +Ve 7- 10 day after 1st missed period Commercial testing kits are available that are sensitive to 25 iu/L in urine.By the time the mother has missed her first menstrual period, her hCG levels are around 100 iu/L.
Serum pregnancy test:Classically it becomes +Ve 5- 7 days before 1 st missed periodA quantitative serum HCG assay level of > 5 iu/L will usually denote a pregnancy.With a normal intrauterine pregnancy, the hCG level doubles approximately every 36-48 hours.
Sure signs of pregnancy:Inspection of fetal parts as early as 20th week. -Inspection of fetal movements as early as 20th week.Palpation of fetal movements as early as 20th week. -Palpation of fetal parts as early as 20th week.
Sure signs of pregnancy-Auscultation of FHS at 10-12 weeks by sonicade Investigations: Visualization of fetal parts by ultrasound
DefinitionAntenatal care refers to the care that is given to an expected mother from time of conception is confirmed until the beginning of laborIt is a preventative cost effective service
GOALS1-Ensure mother health.2- Ensure delivery of a healthy infant.3-Anticipate problem4- Diagnose problem early.
Objectives1-Early detection and if possible, prevention ofcomplications of pregnancy.2-Educate women on danger and emergency signs &symptoms.3-Prepare the woman and her family for childbirth4- Give education & counseling onfamily planning
Schedual of antenatal care: Medical check up every four weeks up to 28 weeks gestation, Every 2 weeks until 36 weeks of gestation Every week until delivery An average 7-11 antenatal visits/pregnancy More frequent visits may be required if complications arise.
On first antenatal visit1-First : Confirm pregnancy by pregnancy test or US.2-History3-Physical examination4-investigation
HistoryPersonal historyMenstrual historyObstetrical historyFamily historyMedical and surgical historyHistory of present pregnancy
Menstrual history- Ask about- 1-Last menstrual period (LMP).- 2-Regularity and frequency of menstrual cycle.- 3-Contraception method used .- 4-Calculate expected date of delivery (EDD) as1st day of LMP −3 months +7 days, and change the year.
Obstetric History Gravidity? Parity? abortion, and living children. Weight of infant at birth & length of gestation. Type of delivery, location of birth, and type of anesthesia. Maternal or infant complications.
Medical and surgical history:1-Chronic conditions : as diabetes mellitus, hypertension, and renal disease ,cardiac disease.2-Prior operation: as cesarean section, genital repair, and cervical cerclag.3-Allergies, and medications.4-Accidents involving injury of the bony pelvis
History of present pregnancy History suggesting e.g. Diabetes, hypertension and ante partum hemorrhage. Ask about episodes of fever or chills Ask about pain or burning sensation on urination. Abnormal vaginal discharge, itching at the vulva or if partner has a urinary problem.
Emergency symptomsVaginal bleedingSevere abdominal ,epigastric, or pelvic painSevere headache with visual disturbancePersistent vomitingUnconscious/ConvulsionSevere difficulty in breathingFever, chills , dysureaAbsent fetal movement
Weight measurementMaternal height and weight measurements to determine body mass index(BMI).Maternal weight should be measured at eachantenatal visit
Check for pallor or anemia.1-Look for palmar pallor.2-Look for conjunctival pallor3-Count respiratory rate in one minute.
Blood pressure measurement Measure BP in sitting position. If diastolic BP is 90 mm Hg or higher repeat measurement after 6 hour rest. If diastolic BP is still 90 mm Hg or higher ask the woman if she has:• Severe headache• Blurred vision• Epigastric pain Check urine for protein.
InvestigationsGet baseline on the first or following the first visit. Hemoglobin, blood type Urine analysis VDRL or RPR to screen for syphilis Hepatitis B surface antigen To detect carrier status or active disease
Provide advice on1.Diet and weight gain2.Medication3.Avoid Radiation exposure4.Self-care during pregnancy5.Minor complaints.6. Family planning Breastfeeding7.Birth place preparation and anticipation of complication& Emergency situations.
Diet in pregnancy: Total caloric intake increase to 300 kcal /day due to 15% increase in BMR .Diet show contain 20%Protein(better from animal source), 30% fat ,and 50% carbohydrates .Sufficient fluids should be available.
Supplementation1-Folic acid 0.4 mg tab daily 2- iron (ferrous sulphate or gluconate )300 mg/daily 3- Ca 1200mg /daily 4-• -Those with a normal balanced diet • probably don’t need extra vitamins
Weight gain in pregnancy:There is a slight loss of pounds during early pregnancy if the patient experiences much nausea and vomiting. Weight gain of 2 to 4 lbs(0,5-1 kg) by the end of the first trimester. Gain of 1 lb(0.5)/ per wk is expected during the second and third trimesters. Monitoring of weight gain should be done in conjunction with close monitoring of BP.
Medications During Pregnancy • Antibiotics - some OK, some not • Local anesthetics - OK • Local with epinephrine - not OK • Aspirin - not OK • Immunizations - some are OK, some are not • Antimalarial - some OK, some are not • Narcotics - OK except for addiction issue
Case Study A 35-year-old G2 P1+0 woman is seen for her first prenatal visit. Based on her LMP, she is at 15 weeks’ gestation. She has no complaints, and no significant medical history. She denies dysuria or urinary urgency.Her surgical history is remarkableHer last delivery was a vaginal delivery and was uncomplicated
On examinationHer blood pressure (BP) is 100/65 mm Hgheart rate (HR)90 (bpm), respiratory rate (RR) 12,temperature 98°F (36.6°C), weight 70KG.general physical examination is normal
Abdominal examination Her abdomen is non tender Fundal height is at the level ofthe umbilicus. Fetal heart tones are 140 bpm. Her extremities are without edema.
Prenatal laboratoriesCBC: Hgb 10.0 g/dL ,Plt 150,000 WBC 8,000Rubella: nonimmune Hepatitis B surface antigen: positiveBlood type: O, Rh negative UC&S: 10,000 cfu/mL of group BstreptococcusGonorrhea assay: negative Chlamydia assay: negative
Questions➤ What items should be listed on the problems list?➤ What is your next step for the problems listed?➤ What other testing should be recommended to the patient?
Problem List:Advanced maternal age 35 Y or greater at EDDfundal height at umbilicus corresponds to 20 weeks) Mild microcytic anemia (Hgb < 10.5) Hepatitis B surface antigen (HBsAg) positive Rh-negative blood type Urine culture with GBS 10,000 cfu/mL,Rubella nonimmune
Next Steps:1. AMA—genetic counseling2. Size/dates—fetal ultrasound to assess GA, multiple gestation3. Anemia—therapeutic trial of iron4. HBsAg positive—check liver function tests, and hepatitis B serology toassess for active hepatitis versus chronic carrier status
Next step5. Rh negative Rhogam at 28 weeks and at delivery if the baby proves to be Rh positive6. Urine culture with GBS—treat with ampicillin and re-culture urine, peni-cillin IV prophylaxis in labor7. Rubella status—vaccinate postpartum
Other tests recommended to patientconsider early diabetic screen